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SCHEDULE

This Schedule forms part of and incorporates by reference LMA3113M (the ‘Agreement’), which Agreement is identified by the Agreement Number and Unique Market Reference Number stated below. For the purposes of interpretation, the contents of this Schedule shall have meaning only as provided for in the Agreement.

|Agreement Number: | |

|Unique Market Reference Number:| |

| | |

|The Coverholder: | |

|Address: | |

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|The Lloyd’s Broker: | |

|Address: | |

| | |

| | |

|AGREEMENT SECTION NUMBER |NARRATIVE | | | |

|Sub-section 2.1 |period: |

| |From: |{Inception Date} | |

| | | | | |

| |To: |{Expiry Date} | |

| | | |Both days inclusive, any time zone |

|Sub-section 3.1 |the person(s) responsible for the overall operation and control: |

| | |

|Sub-section 3.2 |the person(s) authorised to bind insurances: |

| | |

|Sub-section 3.3 |the person(s) with overall responsibility for the issuance of documents evidencing insurances bound: |

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|Sub-section 3.4 |the person(s) authorised to exercise any claims authority: |

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|Sub-section 6.1 |other conditions, requirements and/or amendments relating to the operation of the agreement: |

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|Sub-section 7.1 |authorised class(es) of business and coverage(s): |

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| |(subject to the terms, conditions, exclusions and limitations of the Agreement) |

|Sub-section 8.1.5 |other excluded class(es) of business and coverage(s): |

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|Sub-section 9.1 |risks located in: |

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|Sub-section 9.2 |insureds domiciled in: |

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|Sub-section 9.3 |territorial limits: |

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|Sub-section 10.1 |maximum limits of liability or sums insured: |

|Sub-section 11.1 |basis for the calculation of gross premiums: |

| | |

|Sub-section 11.2 |deductibles and/or excesses: |

| | |

|Sub-section 12.1 |gross premium income limit: |

| | |

|Sub-section 12.2 |notifiable percentage of the limit not to exceed: |

|Sub-section 13.1 |period of insurances bound: |

| |{ } months |

| |maximum period of insurances bound: |

| |{ } months including odd time |

|Sub-section 13.3 |maximum advance period for inception dates: |

| |{ } days |

|Sub-section 16.1 |the coverholder’s commission: |

|Sub-section 16.2 |profit commission(s): |

|Sub-section 19.1 |application or proposal forms: |

|Sub-section 20.1 |wordings, conditions, clauses, endorsements, warranties and exclusions applicable to insurances bound: |

| | |

|Sub-section 20.5 |format of contract documentation: |

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|Sub-section 20.6.9 |several liability notice/clause: |

| |*LSW1001 / LMA5096 |

| | |

| |*(Delete as applicable) |

| | |

|Sub-section 20.6.10 |the name and address to whom the insured should direct all claims: |

|Sub-section 20.8 |combined certificates: |

| |Other Insurers (ie Not Underwriting Members of Lloyd's) |

| |*Permitted / Not permitted |

| |*(Delete as applicable) |

| | |

| |(and subject always to the provisions of Sub-section 20.8) |

| | |

| | |

|Sub-section 20.8.1 |identity of other insurers: |

| | |

|Sub-section 21.1 |authority to handle and/or settle claims and pursue recoveries: |

| |*Yes / No |

| |*(Delete as applicable) |

| | |

| |procedure for the handling and settlement of claims and pursuing recoveries to replace, amend or |

| |supplement section 21: |

| | |

|Sub-section 21.1.1 |per claim limit of authority: |

|Sub-section 21.1.6 |names and addresses of adjusters, surveyors, lawyers or other third parties to be instructed by the |

| |coverholder: |

| | |

|Sub-section 23.1.2 |risks written reporting interval: |

| |*monthly / quarterly |

| |*(Delete as applicable) |

| | |

| |maximum number of days for reporting/submission of risks written bordereau(x): |

| |{ } days |

|Sub-section 23.2.1 |basis of monitoring aggregate exposures: |

|Sub-section 23.2.2 |aggregate reporting interval: |

| |*monthly / quarterly |

| |*(Delete as applicable) |

| | |

| |maximum number of days for reporting/submission of aggregate exposures: |

| |{ } days |

|Sub-section 23.2.3 |maximum total aggregate limit(s): |

| | |

|Sub-section 23.3 |statistical information required by the underwriters: |

| |reporting interval(s): |

| |*monthly / quarterly |

| |*(Delete as applicable) |

| | |

| |maximum number of days: |

| |{ } days |

| | |

| | |

| | |

|Sub-section 24.2 |paid premium reporting interval: |

| |*monthly / quarterly |

| |*(Delete as applicable) |

| | |

|Sub-section 24.3 |claims bordereaux/reporting (paid and outstanding) to be produced/provided by the coverholder: |

| |*Yes / No |

| |claims reporting interval: |

| |*monthly / quarterly |

| |*(Delete as applicable) |

| | |

|Sub-section 24.4 |maximum period for reporting/submission of bordereaux: |

| |{ } days |

|Sub-section 24.6 |maximum period for remittance of settlements: |

| |{ } days |

|Sub-section 24.7 |fees and charges to be deducted by the coverholder: |

|Sub-section 36.1.1 |number of days notice of termination: |

| |{ } days |

| | |

|Sub-section 36.2.2 |name(s) and address(es) to whom coverholder sends notice of termination: |

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| |

|Agreement Number: | |

|Unique Market Reference Number: | |

| | |

| |

|SIGNATURE OF COVERHOLDER |

|In accordance with Section 1 of LMA3113M, the Agreement is signed on behalf of the Coverholder as acceptance of the terms and |

|conditions of the Agreement inclusive of any attachments identified in the Schedule. |

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|Signed and accepted on behalf of the Coverholder |

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|Name and Position of Signatory |

| |

| |

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|Date of Signature |

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LMA3113M

9 October 2015

NON-SCHEDULE AGREEMENTS

|TAX(ES) PAYABLE BY INSURED AND | |

|ADMINISTERED BY INSURERS: | |

|RECORDING, TRANSMITTING AND STORING | |

|INFORMATION: | |

INFORMATION

SECURITY DETAILS

| | |

|ORDER HEREON: | |

|Basis of Written Lines: | |

|BASIS OF SIGNED LINES: | |

|SIGNING PROVISIONS: | |

N.B. The written lines for the Binding Authority agreement should appear here.

The Several Liability clause to be used for each certificate should be specified within the schedule

SUBSCRIPTION AGREEMENT

|SLIP LEADER: | |

|BUREAU LEADER: | |

|SETTLEMENT TERMS: | |

|BASIS OF AGREEMENT TO BINDING | |

|AUTHORITY CHANGES: | |

|BINDING AUTHORITY ADMINISTRATION: | |

|BINDING AUTHORITY AGREEMENT | |

|PRODUCTION: | |

|BASIS OF CLAIMS AGREEMENT: | |

|CLAIMS AGREEMENT PARTIES: | |

|RULES AND EXTENT OF ANY OTHER | |

|DELEGATED CLAIMS AUTHORITY: | |

|EXPERT(S) FEE COLLECTION: | |

|BUREAU ARRANGEMENTS: | |

|SPECIAL ARRANGEMENTS: | |

FISCAL AND REGULATORY

|TAX PAYABLE BY INSURER(S): | |

|US CLASSIFICATION: | |

|NAIC CODES: | |

|PIN(S) | |

|BINDING AUTHORITY REGISTRATION DATE| |

|AND NUMBER: | |

|ALLOCATION OF PREMIUM TO CODING: | |

|REGULATORY CLIENT CLASSIFICATION: | |

|IS THE BUSINESS SUBJECT TO DISTANCE| |

|MARKETING DIRECTIVE?: | |

BROKER REMUNERATION AND DEDUCTIONS

|TOTAL BROKERAGE: | |

|OTHER DEDUCTIONS FROM PREMIUM: | |

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